Hamish Dibley

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Delaying the inevitable: a better way to think about delayed transfers of care

DTOCDelayed transfers of care, or ‘DTOC’ as it is colloquially referred to in NHS circles, is an entrenched national problem. It is often claimed that a combination of ‘cultural and structural factors’, an over-reliance in bed-based care and increasing numbers of people with complex conditions moving between providers is causing undue strain on the system. It is one of the principal issues said to affect the performance of A&E units up and down the country.

DTOC has a big impact across the whole healthcare economy in terms of activity, costs and reputation. It is generally accepted to centre on acute services for older people. But the question I pose is: by focusing on the acute are we concentrating efforts on the symptom or the cause? Every problem presents an opportunity. Every challenge requires an intention to signal a desire to improve through thinking and acting differently. DTOC is a symptom of a dysfunctional health care economy.

Concerted effort and numerous attempts have been made, over several years, to successfully address DTOC. These initiatives include the usual list of initiatives including ‘Appropriate Care for Everyone Programmes’ (without ever defining what appropriate in this context means), QIPP projects, engagement and public education packages and Older People’s Joint Commissioning Strategies.

Yet, successive schemes fail to impact on DTOC as they compartmentalise the problem through focusing on urgent care or complex care rather than understanding the root cause of the problems. The impact of these actions on improving DTOC performance remains stubbornly low. Initiatives tend to adopt a reactive and reductionist approach to resolving the problem.

The principal reasons for failure requires detailed study but can be summarised by adopting a (silo) service-first not patient-perspective and focusing on activity reduction and discharge pathways. The causes of waste or ‘system limitations’ affecting DTOC include:

  • Outsourcing of adult social care provision
  • Multiple patient assessments
  • Eligibility criteria in community and social care
  • Different organisational budgets, performance metrics and ways of working
  • Counter-productive financial incentives across the system
  • Service fragmentation such as a ‘medically fit’ focus
  • Alleged risk-averse attitudes amongst some clinical staff
  • An efficiency rather than effectiveness focus on reducing length of stay
  • A target mentality which limits attempts to understand in order to improve
  • Understanding the problem from the organisational perspective

‘Pooled budgets’ for services used by older people offers hope to reduce rates but only if it is accompanied by a change in commissioning and operational thinking and ways of working that extends beyond joint ‘commissioning of care’.

‘Current DTOC performance’ is monitored on a regular basis through weekly returns taken on one day each week from local acute trusts. The whole thing resembles the game-show Play Your Cards Right. Snapshot analysis shows the weekly rates of DTOC can vary with some weeks being ‘higher’ and others ‘lower’.

All of which leaves me with more questions than answers, and those questions are – what does this tell us? How does this information help us understand to improve? Does this ‘activity counting’ help develop knowledge and understanding around the patients who experience delays and the type and nature of activity this creates which leads to costs? What has operationally changed as a result of monitoring? How do we know if this has been effective? Or like the game show – is it simply a game of chance? Such ‘activity monitoring’ is as counter-productive as it is distorting. Improvement work must take place in the work not in meeting rooms.

I have recently completed a piece of work looking at the problem. I hope the study will provide the platform to overcome successive false starts, identify root causes and design a healthcare system to reduce DTOC levels through better understanding patient demand. But that, of course, is dependent on the willingness of local NHS leaders to adopt a different mindset.

It begins with adopting a different patient-centred perspective and intelligently analysing the problem. This work seeks to take a holistic approach and understand it from the patient perspective. It asks how many patients cause what type, patterns, predictability and volume of activity which results in costs. This way of thinking and acting is the means to achieve intelligent change leading to sustainable performance improvement.

What you discover is that the DTOC problem is NOT a general acute service for older people problem; hospitals deal with the consequences of the issue. When you compare A&E waiting time against DTOC rates it reveals different sets of challenges. One lot are external system problems where the acute provider is trying to deal with the consequences of fragmented care. But there are also internal system issues such as the impact of the 4-hour waiting time target which distorts performance and paradoxically helps make the problem worse (see my previous blog on the deficiencies with the A&E waiting time target).

As ever with healthcare, DTOC is a ‘vital few’ challenge – small numbers of patients consuming disproportionately high levels of activity, capacity and resources. For example, 1,700 patients admitted suffered with a DTOC over a 12 month period. The length of stay from their emergency admissions contributed to a third of the overall bed capacity of the hospital. Moreover, the real costs of DTOC are much higher than simply a blinkered focus on ‘excess bed days’ would allow for (an abstract and unhelpful financial ‘tariff’ distinction). Less than 2,000 people cost this particular secondary care system over £11 million every year. How much of this money is well spent? We simply don’t know.

But the small numbers show that the problem is predictable and therefore manageable.  It also represents a big opportunity providing healthcare leaders have the courage to make profound changes in the way we commission and provide healthcare services. To improve (and thereby reduce) DTOC there is a need to better understand patients and what services they already consume to design more effective medical and non-medical services around their care needs.

The issues affecting DTOC are complex. The mistake often made with improvement efforts is to try and cut through or standardise complexity. Wrong. As W Ross Ashby’s Law of Requisite Variety teaches us the most intelligent way to deal with variety is design systems and services against that variety. In healthcare the way to undertake this is to understand and then design against patient-level demand. This will be effective and if you think about it, if you are effective at something; by definition you will be efficient.

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The Consumption Demand Method™ – ‘Front-to-Back Thinking’ for a Better NHS

 The Consumption Demand Method ™

The Perceived Problems

Healthcare providers and commissioners face multiple challenges. They increasingly recognise that the NHS must change the way it operates to effectively meet future challenges. Commonly held opinions dominate discussion – from a belief in rising demand for healthcare services, costs associated with technological and treatment advances, increasing public expectations and a funding gap of £30 billion.

Conventional Approach to Change

Conventional approaches adopt an internal activity and cost-reduction focus. They typically involve workshops to agree service models and action plans. These tend to be accompanied by artificial modelling of service capacity and staff resourcing which arrive at ‘optimum levels’ of activity ‘contacts’ that are then tested in workshop environments. Following this type of analysis, work is undertaken to standardise service processes so as to reduce variation and waste.

Inherent within this approach is a belief that there is a capacity problem; solutions can be found via workshops and abstract planning models that determine staff resourcing. Workforce planning often ensues to try and address the perceived problem of the ‘plateaued worker’. The logic equates to stable staffing levels and standardised processes which will lead to activity and cost reduction gains. Standardising processes typically take place in workshop environments, far are removed from where the real work occurs.

Yet, in service organisations, seeking to standardise processes often creates problems. In healthcare there is high variability of patient demand; standardising processes will only cause service performance to fall (as the standard offering fails to meet the natural variation in needs) and costs increase (as the service provider’s standard work leads to more activity creating additional process waste and rework).

Adopting a Different Tact for Better Results

To address these challenges I have pioneered a new and refreshing approach to healthcare analysis – the Consumption Demand Method™. The starting point for improved services at less cost rests on more intelligent use of data to inform future performance improvement through intelligent system and service redesign. This alternative approach to realising better healthcare services and less cost begins with looking at healthcare data differently, not from an activity but patient-centred perspective.

Unlike existing practice, this work establishes time-series data to understand the true nature of person-demand for acute services in order to better understand the root-cause(s) of service challenges facing healthcare commissioners and providers alike. From understanding patient demands it is possible to develop knowledge as to ‘who, where and why’ these demands exist in the first place and how best to meet them in order to provide more effective, person-centred services at less expense.

The Method is directly influencing commissioners and providers, helping to challenge conventional thinking about healthcare demand. A recent study of secondary healthcare demand reveals counter-intuitive truths about the true nature of service demand. Unlike activity-levels, patient-centred demand in secondary care is not rising, but entirely stable and predictable. This is bad but good news.

Rather the root-cause for increases in activity (and associated costs) lay in the inability to successfully design service responses based on genuine understanding of patient needs. This inability drives ‘amplification of demand’ from relatively small numbers of patients – the ‘vital few’.

I have utilised the Method to establish a series of ‘demand-led’ improvement projects. These include work in the following areas:

  • Primary care transformation
  • Delayed transfers of care (DTOC)
  • Accident and emergency
  • Referral time to treatment (RTT)
  • Integrated diabetes service
  • Sustained high-cost users
  • Long-term conditions
  • Out-of-hours provision
  • NHS 111

Moreover, the Method has also been successfully used to perform wide-ranging reviews of medical specialities and existing improvement schemes. One such review of a two-year QIPP scheme in paediatric urgent care, which cost seven figures to resource, found that the local healthcare economy would have saved more money by not doing anything! The work analysed demand for services against stated project aims, proposed changes in both design and process and realised operational savings.

The approach and work also acts as a catalyst in providing knowledge and skills transfer to senior clinicians, commissioners and specialists in the analysis of consumption data and redesign of service models and care systems against patient-level demand as opposed to arbitrary and abstract activity indicators.

In fact, the Method effectively identifies ‘business gaps’, encourages thinking about the real problems, asks intelligent questions and provides the means to sustainably improve performance. It deliberately keeps abstract programme and project management, risk assessments and associated document reporting to a minimum as they impede real change.

More intelligent use of data in this way can better inform future commissioning and operational improvement through system and service redesign. After all the NHS has exhausted all other misguided approaches – standardising; over-medicalising; functionalising and commercialising operations. We need to humanise healthcare and focus as much on care needs as medical treatments.

For more information see Front-to-Back Thinking – humanising healthcare – Dibley Consulting or contact me at hamish@dibleyconsulting.com

The need to humanise health and civilise care

Front-to-Back ThinkingWith NHS England’s ‘Five Year Forward View’ talking about the need to change to cope with ‘rising demand’ and last week’s Autumn Statement assigning billions more pounds to the NHS I thought it was a good time to reflect on the state of healthcare in the UK. The whole purpose of my work is to challenge convention (and boy does convention require challenging) by looking at (and creating different) data to understand person demand not arbitrary activity and cost data. Too much work in healthcare is driven by unthinking opinion or hunch – ‘I think therefore let’s do’ and we assume everything is a capacity problem and that there is no waste in the way things currently work.

Yet, if you base work off opinions you are guaranteed to waste millions and this is what happens predictably in Quality Innovation Productivity and Prevention (QIPP) and Cost Improvement Project (CIP) land every single year (which then leads us to say we haven’t got enough money – a vicious circle). This is a systematic issue not a people one. People’s behaviour – whether they are patients or professionals tends to be driven the system not the other way round. I recognise that whenever someone challenges convention they will be dismissed, ridiculed, ignored, and attacked or all of the above! So I try in my work to create inquisitiveness amongst people because the curious person will be the one who seeks greater understanding and from that knowledge. In healthcare to realise sustainable improvement we need to adopt a different perspective and think (and act) ‘front-to-back’.

I’m often asked where such a detailed focus on ‘front-to-back’ analysis will take us. Well, off the back of clever person-level data across the whole healthcare system we can then begin to think about intelligent redesign based on designing for value (set against what good looks like, not from the perspective of the commissioner or provider but the person/relative/guardian who experiences it) and design out or reduce non-value work (and yes, it does exist in health as it does in any other service environment); understand service capability set against current ‘value’ demand for these services; and then and only then look at the work process itself – how does the actually work flow – we have zillions of processes in health. In any process there are only two types of activity going on – value work and waste. The aim is to study, understand and improve the value and remove the waste. This should be the focus of improvement activity that goes on in the work itself, not in board or meeting rooms with flip-chart papers, post-it notes, talking about (often fictional) interpretations of ‘as-is’ and ‘to be’ models. It is what I call ‘intelligent system and service redesign’ and is as different, challenging but enlightening as the approach to data analysis.

Currently, the way we design, manage and measure healthcare is arbitrary and reductionist; from artificial boundaries we call primary, community, secondary, social care to emergency versus urgent versus planned care; the way we devise and manage budgets (we need to move away from service-level to people-level reporting); the codes and performance measures we use (and here we need operational coding and capability measures not arbitrary targets that distort performance; the way we align (or more often misalign) human resources; the IT we use; the contracts we have in place (which are always developed in response to the last 12-month activity data which is statistically daft and therein lies much waste of time, effort and resource). All of this occurs because we do not study and design services and systems against real person demand. Persons (or the labels we give them – patients/service users) actually flow through systems – we need to think and act horizontally not vertically.

Moreover, we must ‘trust’ healthcare professionals to be just that, professional. We rightly pay a fortune to train-up folk and then regressively undermine their very autonomy and judgment through rules, regulations, so-called standards, protocols, directives often set by people far removed from the real work. One of the biggest problems now facing parts of the system is the fact that over recent times we have deliberately dumbed down skills mixes, for example, in adult social care where eligibility criteria explicitly exists to restrict access to support and therefore push disproportionate numbers of ‘people’ with social care and psychological needs into a transactional medical establishment called a hospital where professionals who are not best equipped to deal with ‘help me’ needs honourably struggle. The false economy in all of this is massive.

In some parts of the country commercial providers who run community services now expect district nurses to work to an artificial ‘schedule of rates’ and the ticking clock (this task should take this time and no more). This practice is called activity management and results in the distortion of just about everything. In one particular locality it results in good nurses leaving (as they are doing in their droves) and where they are able to replace them they do so with cheaper staff or agency. This results in cheaper transaction costs for the commercial provider and the ability of that provider to say to the commissioner look we have saved X in activity and costs. Yet the total costs will be XXXX higher as poor care results in people bouncing around the system more often. And I know this is happening because the particular commissioner has just reactively agreed to spend more money it claims it doesn’t have to fund the acute provider to undertake community outreach services to stop so many of these folk coming in! So the commissioner is in effect paying twice for a service while the problem is with the very (activity and cost driven) way the contract has been agreed with the commercial community services provider!! You couldn’t make it up.

I have seen enough of healthcare (in the round – it is imperative not to separate or divorce social from community from primary and secondary) both professionally and personally to think there is a better way, I’m convinced of that. My work is an attempt to systematically humanise health and civilise care as opposed to thinking the future lies in over-medicalising, commercialising or functionalising provision. With the latter three approaches, we have tried and are continuing to try this with disastrous consequences for both patients and taxpayers. I believe the former perspective is the missing feature for a smart health and care system. Now that’s a benevolent vision that’s worth striving for.

‘Front-to-back’ thinking: the antidote to activity obsession disorder in the NHS

Activity obsession disorder: a curable condition

Activity obsession disorder: a curable condition

In healthcare we obsess with the wrong perspective – I call it ‘back-to-front’ thinking and it drives all NHS healthcare activity. It begins with asking the wrong questions of data, fixating on activity levels and volumes. The logic is as simple as it is unthinking: every annual budget cycle; we try to reduce costs by reducing XX% activity. The one problem with this approach – it never works. Costs spiral ever upwards whilst service outcomes either flat-line or reduce.

In NHS language this results paradoxically in an “over-performance” problem (which sounds positive but is in fact bad) – doing more activity than was stipulated in the contract plan. Consequentially, this leads to a counter-productive reliance on confrontational contracting as the primary commissioning lever. ‘Quality guru’ Brian Joiner refers to this type of behaviour as distorting the figures and the system. Everybody loses. We can’t afford to continue working in this manner.

In fact, it doesn’t have to be this way. There is an approach that is as different as it is revolutionary and has the potential transform healthcare. It can provide commissioners and providers with the wherewithal to achieve meaningful and sustainable change. The better alternative – what I call ‘front-to-back’ thinking is to start with looking differently at the data (as well as using innovative methods to generate new patient-centred data).

‘Front-to-back’ involves studying the nature demand for healthcare services not from the perspective of arbitrary activity numbers but real patients over time-series data. What this typically reveals is that the problem acute trusts think they have – one of rising demand is not actually true. The real problem is what I call ‘boomerang’ demand: comparatively small numbers of patients consuming disproportionate amounts of activity and resource as a consequence of services that are not designed for them.

Asking ‘front-to-back’ questions allows you to study the nature of activity that takes place on patients – how much is good versus wasted work; how much can be redesigned to work differently; how much activity actually should take place at different times, in different ways or not at all! Utilising this approach and its way of thinking then allows healthcare providers and commissioners the knowledge to undertake ‘intelligent system and service redesign’ around cohorts of patients not abstract service pathways.

The holy-grail of better services at less cost is achievable in health but it requires a different way of thinking and then acting based on what empirical data, not opinion, tells us. We can do much better than have to continuously rely on and fail with activity management approaches. Activity obsession disorder is a serious but curable management condition.

‘Back-to-front’ thinking: right care, wrong approach

Back to Front

I recently attended an intriguing presentation on NHS Right Care. Right Care is an approach to improvement that affords health commissioners with a way to substantially improve ‘health outcomes, value and financial sustainability’. The approach provides the methodological underpinnings to the Commissioning for Value programme which is about identifying priority programmes to offer the best opportunities to improve healthcare. The work is promoted as having a ‘compelling economic narrative that creates a national benchmark and peer comparison’ and that it should be ‘business as usual’. It was this acclaim that got me thinking about the right way to study to obtain good care and the role of standard improvement tools.

A common error with many analytical models is to draw linkages between correlation and causation or indeed assert causality as a consequence of data analysis. Results from quantitative data analysis require empirical validation in real-world conditions. Data analysis asks ‘what’ questions that needs to be linked to pursuit of ‘why’ to authenticate findings. For example, quantitative datasets such as those captured by acute hospital trusts and GP practice data will only tell us ‘what’ is happening. You need other techniques that will reveal why. For example, the purpose of more qualitative methods is to understand ‘why’ and ‘how and where’ to improve. You cannot improve with confidence solely on the basis of ‘what’ findings.

As for the Right Care Methodology I believe its premise is wrong. It represents what I call ‘back-to-front’ thinking with the emphasis being on activity and costs. Essentially reductionist by design (not systematic) and a silo focus on pathways and prizing indicative over empirical evidence. From what I could tell listening to a presentation about the approach and reading the material, Right Care relies on standardised benchmarking and peer-to-peer comparisons. Both approaches have distinct limitations in terms of understanding and identifying performance issues. Indeed, the resulting ‘prioritisation of ideas’ relies on indicative costs which I would suggest lacks rigour and robustness.

The approach relies heavily on benchmarking as a tool for performance improvement. Yet, as I have already blogged about, it is important to recognise the limitations inherent with benchmarking. As an improvement tool, it is only as meaningful as those you are measuring against. Moreover, caution is to be exercised where current performance is significantly better than average but falls short of either Clinical Commissioning Group (CCG) or provider performance ambitions.

Indeed, benchmarking has merits in demonstrating ‘big-picture’ cost comparisons. But is poor at understanding context, value and total costs and should not be used in isolation to either understand or improve service performance. For example, whilst some indicators would imply positive performance around a specialty, local clinical intelligence offers a different story. Furthermore, there may be other indicators that a CCG or provider would like to consider itself against, other than the nationally available data.

Moreover, it cannot provide the means to understand and improve performance. With benchmarking, it’s important to know what you are comparing. And if what you are comparing is actually comparable. I am of the evidential opinion that the only benchmarking and best practice you should do should be within your own organisation, complimented and cross-referenced by other more robust techniques to achieve more comprehensive understanding and analysis.

We need to start moving beyond benchmarking and standardised pathways (for me Right Care is about perceived pathway efficiency not about patients – that term that is hardly ever used and certainly wasn’t in presentation I attended) towards consideration of models of care tailored to patient cohorts founded upon comprehensive research and analysis – both quantitative and qualitative in origin. Instead of obsessing about activity numbers and financial costs, we need to think about purpose and process. Systems and processes determine service effectiveness and cost efficiency. The purpose of any service comes from the people/users/patients/customers. If you improve the process based on the purpose, better outcomes and cost savings follow. That’s what I mean by ‘Front-to-Back Thinking’. Off the back of this you can then engage in what I call ‘intelligent system and service redesign’. I’ll on this theme at a future time.

Apples and pears: a word of caution on benchmarking in healthcare

The limitations of benchmarking

The limitations of benchmarking

Benchmarking has some merits in demonstrating ‘big-picture’ cost comparisons. But it is poor at understanding context, value and total costs. Moreover, it can’t provide the means to understand and improve performance. With benchmarking, it’s important to know what you are comparing; and if what you are comparing is actually comparable at a finer level of analysis e.g. disease conditions. Otherwise it’s like contrasting apples and pears.

Take the argument around using Dr Foster’s standardised measuring of mortality. Professor Nick Black was asked to look into mortality rates following a review by Sir Bruce Keogh in July 2013 found failings in care at 14 hospitals with the highest death rates. Professor Black argues that the two principal mortality measures are not an accurate indicator of poor care and should be ignored. Death statistics as influences of hospital care quality is a very ‘weak signal’ at best or a ‘distraction’.

One of these is Hospital Standardised Mortality Rates (HSMR). HSMR looks at the expected rate of death with actual rates. HSMR is a very dubious overall measurement of mortality – the numbers being influenced by the way hospitals collect data, changes in coding can alter mortality statistics. HSMRs do not take account of factors including the availability of hospice care – less hospice care is likely to lead to more people likely to die in hospital but be no reflection on the quality of acute care.

This can result in misunderstanding data e.g. Royal Bolton Hospital following a Dr Foster benchmarked audit is a case-in-point. It is worth a listen: BBC Radio 4 File on 4 Programme